Mechanism Action of Statin

• HMG CoA reductase inhibitor  inhibit cholesterol production

• The available agents of this group, in increasing order of potency  Fluvastatin, Lovastatin, Simvastatin,
Atorvastatin, and Rosuvastatin
• Reduce LDL serum through 3 mechanism :
1. Reduce intrahepatic cholesterol  increase expression of the LDL receptor gene  greater number of
LDL receptors on the surface of the hepatocytes  binding and clearence of LDL from the circulation
2. VLDL and IDL cleared more rapidly from the circulation because of their cross-recognition with the
hepatic LDL receptor
3. Reduced availability of intracelullar cholesterol for lipoprotein  hepatic VLDL production fall 
catabolism of VLDL   circulating LDL level 

Lilly LS. Pathophysiology of Heart Disease: A Collaboartive

Project of Medical Students and Faculty. edition 5. Philadelphia
: Lippincott William Wilkins.2011.
 Mechanism Action of Statin
• The lowering of LDL reduces the lipid content of atherosclerotic
lesions  plaque stability  decrease likelihood of thrombus
formation and vascular occlusion
• Cardioprotective effect
1.  No synthesis
2. Inhibiting monocyte penetration into arterial wall
3. Reducing machrophage secretion of MMP
4. Inhibiting the unregulated uptake of modified LDL cholesterol by
machrophage
5. Suppress inflammation
Lilly LS. Pathophysiology of Heart Disease: A Collaboartive
Project of Medical Students and Faculty. edition 5. Philadelphia
: Lippincott William Wilkins.2011.
Pleiotropic (cholesterol-independent) Effect of
Statin
• Improving endothelial function
• Enhancing the stability of atherosclerotic plaques
• Decreasing oxidative stress and inflammation
• Inhibiting the thrombogenic response
CHA2DS2 VASc Score

HAS BLED Score

 CHA2DS2 VASc Score
• Score ini digunakan untuk mengukur resiko stroke pada pasien yang
mengalami atrial fibrilasi
• Panduan pemberian antikoagulan oral untuk pencegahan stroke
• Atrial fibrilasi  aritmia tersering yang berkaitan dengan stroke
tromboemboli
• AF  stasis of blood in the upper heart chamber  formation of mural
thrombus  dislodge into the blood flow  reach the brain  cut off
supply to the brain  stroke
 CHA2DS2 VASc Score

Guidelines for the management of atrial fibrilation. European Heart Journal (2010) 31, 2369 - 2429
 CHA2DS2 VASc Score

KLASIFIKASI CHA2DS2 VASc

Score
1. Low risk = 0
2. Moderate risk = 1
3. High risk = ≥ 2

Guidelines for the management of atrial fibrilation. European Heart Journal (2010) 31, 2369 - 2429
Oral Anticoagulant :
1. Warfarin (INR 2.0 – 3.0)
2. New oral anticoagulant (Apixaban, rivoraxaban, dabigatran)

Guidelines for the management of atrial fibrilation. European Heart Journal (2010) 31, 2369 - 2429
 HAS BLED SCORE
• To assess bleeding risk in AF patients
• Intracranial bleeding increases with INR values > 3.5 – 4.0, and there is no
increment in bleeding risk with INR values between 2.0 – 3.0 compared with
lower INR values
• The HAS BLED score  good predictive value for intracranial bleeding
• The HAS BLED score makes clinicians think about the potentially
reversible risk factor for bleeding
 HAS BLED SCORE

1. Hypertension : SBP > 160 mmHg

2. Abnormal renal function : presence chronic dialysis or
renal transplantation or serum creatinin ≥ 200 umol/L
3. Abnormal liver function : chronic hepatic disease (eg.
cirrhosis) or significant hepatic derangement (bilirubin > 2
x upper limit of normal, AST/ALT > 3 x upper limit of
normal)
4. Bleeding : previous bleeding history and/or predisposition
to bleeding (bleeding diasthesis, anemia)
5. Labile INRs : unstable/high INRs or poor time in
therapeutic range (eg. < 60%)
6. Drugs or alcohol : antiplatelet agents, NSAID
Guidelines for the management of atrial fibrilation. European Heart Journal (2010) 31, 2369 - 2429
 - Score ≥ 3
indicates increased
1 year bleed risk on
anticoagulant
sufficient to justify
caution or more
regular review

Guidelines for the management of atrial fibrilation. European Heart Journal (2010) 31, 2369 - 2429
• In patients with NSTEMI  dual antiplatelet therapy is recommended
(aspirin + clopidogrel), but in AF patients at MODERATE to HIGH RISK
of STROKE  OAC should be given
• In acute setting  aspirin + clopidogrel + UFH or LMWH (enoxaparin) or
bivalirudin or GP IIb/IIIa inhibitor
• For medium to long term management, triple therapy (VKA,aspirin, and
clopidogrel) should be used in the initial periode (3-6 months) or for longer
in selected patients at low bleeding risk.
• In patients with high risk cardiovascular thrombotic complication ( GRACE
or TIMI Risk Score), long term therapy with VKA combined with
clopidogrel 75 mg daily (or aspirin 75-100 mg daily) + gastric protection for
12 months